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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180955 6/24/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> GSG GAS & FOOD <br /> Business Site Address City ZIP Code <br /> 701 E CHARTER WAY STOCKTON , CA 95206 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> FELIX RAMIREZ (209 ) 744- 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08 - 1740 5 -31 -20 8883072 - UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling We EBW & Phil Tite # 1009883708 11 /29/20 <br /> OPW #104634 3- 14-20 4 J7 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : LAKE TESL" <br /> ENVIR - <br /> ❑ Industry Code or Engineering Standard (Specify) : nrhPARIJV F1 I . I- <br /> ❑ Engineered Method (Specify) : <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, stored product, etc.) 87 91 <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic 0 Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) <br /> Inside Diameter of Spill Container: (Inches) 11 11 <br /> Depth of Spill Container: (Inches) 15 15 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No Rx Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: 0 Drain Valve Z Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: 0 Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked Fail' above must be explained in this section. Any additional comments may also be provided here. <br /> VIE CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations , Title 23, Division 3 , <br /> Chapter 16 , Section 2637 . 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature , <br /> r; f <br /> /f the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Caliifomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />